A New Model for Dealing with Patients Who Frequently Arrive

Persson L et al., Int J Nurs Clin Pract 2014, 1: 103 http://dx.doi.org/10.15344/2394-4978/2014/103

International Journal of Nursing & Clinical Practices Research Article Open Access A New Model for Dealing with Patients Who Frequently Arrive Spontaneously at Hospital Emergency Departments Requiring Health Care: A Pilot Study Lena Persson*, Ingela Furenback and Liselotte Jakobsson School of Health and Society, Kristianstad University, Elmetorpsvagen 15, 29188 Kristianstad, Sweden Abstract Publication History: Received: September 08, 2014 Background: Patients who repeatedly seek care directly at hospital based somatic emergency Accepted: November 17, 2014 departments take up a large proportion of health care resources, at the same time they appear to Published: November 19, 2014 experience low satisfaction with the care they receive. The purposes of this pilot study were to describe: I) the development of a team model for taking care of frequent visitors to a somatic hospital based ED; II) Eventual changes, over six months, in costs and patients’ health care utilization related to pilot testing Keywords: the model and III), the team’s experiences of implementing the model. Emergency nursing, Frequent Methods: A mixed method convergent parallel design was used. visitors, Interprofessional Results: The development of the model began as a top-down process and later on into a bottom-up collaboration, Team-based practice approach once the inter-professional team became involved. The new model functioned as a support for all 12 patients included in the study and collectively their visits decreased by a total of 73 visits (55%). Conclusion: The inference quality description is that a management induced project may be accepted and actively applied when those involved experience freedom to structure the project. Increased communication between different professionals within the hospital and between different caregivers such as ED, primary health care and community social- and health-care, increases the possibility for the patients to be cared for in a sustainable and non-fragmented way. Background identified elsewhere are those with chronically severe medical There is an ongoing debate in the community in Western countries problems, [13], or mental and behavioural disorders [14], or suffer about what is the right use of hospital emergency departments (ED) from co-morbidity related to somatic concerns, psychiatric illness and how to best take care of the needs of an increasing proportion and substance abuse [15]. These patients engage a large proportion of of the population who use them. People who repeatedly seek care health care resources while at the same time they appear to experience through ED are engaging a large portion of health care resources and less satisfaction with the health care system than other patient groups experience greater dissatisfaction with health care than other patient [2,3]. These circumstances create frustration among the staff as well as groups. This creates frustration for the staff within the health care and increased suffering for the patients [1]. The findings have resulted in involves suffering for the patient. These patients often present multiple an ongoing debate among health care providers concerning both the diseases with high grad of mental illness [1-3]. In order to offer an objectives of somatic hospital based ED and how to provide the best effective and safe treatment in which care is provided at the right practice when taking care of patients who frequently visit a hospital level and to avoid repeated visits to the ED a good communication based ED [1,16,17]. Some beneficial results have been found in and close collaboration is needed between the hospital specialist studies covering the effectiveness of case management (CM). Kumar care, primary care, community care and informal care [1,4]. General & Klein [18] showed, in their literature review, that intensive CM research evidence are lacking for how these people should be taken reduced the cost and number of ED visits. The content of such a care of in an optimal way. Some studies, though, show a need for CM programme involved frequent follow-up of patients, availability continuity and collaboration between health care providers to avoid of psychosocial services and finance entitlements plus a high level of deficiencies in the quality and high total cost of care [1-4]. Reasonably patient involvement in care planning. Although the literature review this is applicable to various ED care, however little described for presented beneficial outcomes in providing intensive CM at somatic frequent visitors to an ED department. hospital based ED, the authors concluded that there was a need for further studies covering how best to take care of frequent visitors The objective of somatic hospital based ED is to provide highly to ED. This is a conclusion which is supported by other researchers professional care to patients who are in need of urgent or emergency [8,19-21]. In Sweden and, to our knowledge, no intervention study somatic care at any time of the day. The care provided has to be based on evidence based medical practice as well as on individually *Corresponding Author: Lena Persson, School of Health and Society, based nursing [5,6]. However, during the last decades the function Kristianstad University, Elmetorpsvagen 15, 29188 Kristianstad, Sweden; E-mail: of somatic hospital based ED has gradually changed, mainly due to [email protected] the characteristics of today’s patients visiting ED. For example, studies from Western countries point out that patients nowadays’ more often Citation: Persson L, Furenback I, Jakobsson L (2014) A New Model for Dealing with Patients Who Frequently Arrive Spontaneously at Hospital Emergency use somatic hospital based ED for reasons that are beyond somatic Departments Requiring Health Care: A Pilot Study. Int J Nurs Clin Pract 1: 103. concerns and are in fact based on psychological and social reasons doi: http://dx.doi.org/10.15344/2394-4978/2014/103 [3,7,8]. Prior studies has shown that ED frequent visitors are a Copyright: © 2014 Persson et al. This is an open-access article distributed psychosocial vulnerable group with poor mental health, low level of under the terms of the Creative Commons Attribution License, which permits perceived social support and heavy users of general practitioners and unrestricted use, distribution, and reproduction in any medium, provided the other primary care forms [9-12]. Further groups of frequent visitors original author and source are credited.

Int J Nurs Clin Pract IJNCP, an open access journal ISSN: 2394-4978 Volume 1. 2014. 103 Citation: Persson L, Furenback I, Jakobsson L (2014) A New Model for Dealing with Patients Who Frequently Arrive Spontaneously at Hospital Emergency Departments Requiring Health Care: A Pilot Study. Int J Nurs Clin Pract 1: 103. doi: http://dx.doi.org/10.15344/2394-4978/2014/103

Page 2 of 6 covering models for reducing costs and frequent visits at ED has triage nurse and patients with self-injurious behavior. The reason for been published. The purpose of this study was to describe: I) the their exclusion was that they were already included in the system and development of a team model for taking care of frequent visitors in a that they would perhaps profit from ED care. somatic hospital based ED; II) eventual changes after six months in costs and patients’ health care utilization related to pilot testing and During the 3 month period March to May 2012 patients were III) the team’s working experience of the model. included consecutively. In total, 180 people sought care at the hospital ED and met a physician, more than four times counted from January Methods 2012. Of these, 92 patients met the inclusion criteria, however, only 25 were asked to participate in this study, 12 accepted, three declined and This study was performed using a convergent parallel mixed method 10 patients wished to be contacted later. The remaining 67 patients, approach [22] involving the collection and analysis of quantitative who met the inclusion criteria, were not invited to participate for and qualitative data. various reasons. The most common reasons where the emergency nurse’s shortage of time (n=40) as she was the key person in the team, Quantitative data concerning patients´ characteristics were collected then patients with separate diagnosis (e.g. gallstones or kidney stone) with regard to their gender, age, housing situation, social, work and (n=22) and other causes (n=5). economic situation. Also information regarding who had initiated the patient’s contact with ED, the method of their transportation to ED, When the patient was admitted to the ED, the emergency nurse any previous support from the municipality and whether or not a contacted them to ask for their informed consent to partake in the previously planned care appointment had been fulfilled. study. Patients who already were discharged were contacted by phone. For collecting data about the patients a standardized questionnaire To identify changes in patients’ search patterns from the ED data was applied, with questions complementing patients’ records and were collected from the hospital. The data consisted of patient records the assessment of patients’ status. The Prime MD (Primary care and statistics about patients’ health care utilization. Data, such as the evaluation of mental disorders) was used to evaluate mood, anxiety, number of visits, was compared from six months prior to the patient’s somatoform, and alcohol and eating disorders [25,26] The form was inclusion in the study to six months after. An economic evaluation further complemented with four questions regarding physical and was conducted using the hospital's standardized cost calculation for a psychological abuse. patient visit to the ED. To evaluate the staff’s experience of the model qualitative interviews Qualitative data was collected by interviewing staff included in were conducted [27], either individually or in groups, focusing the Executive inter-professional team and the project manager, on their own experience. The interviews were tape recorded and either individually or in groups. The interviews focused on the staff’s analyzed using conventional content analysis [28]. The data analysis experience of working with the model, their experience of professional began with reading the transcribed interviews repeatedly, using an collaboration and the strengths and weaknesses of the new approach. open mind, in order to get a feeling for the whole. In a second phase the researcher made notes of her first impressions, thoughts and made Setting an initial analysis. As this process continued code labels emerged The study was performed at a Central Hospital in southern Sweden, which became the initial coding scheme. The codes were then sorted serving a catchment area of about 180 000 inhabitants. A survey of into subcategories and categories based on how they were related and health care utilization made 2009 (12 months) revealed that18 875 linked. patients aged 20 years or older sought care through the ED and met a Ethical consideration physician. Of these, 906 patients (4.8%) sought and received care four or more times during 12 months. The group accounted for 4 742 visits, The patients included in the study gave their written informed representing 16.8% of the total number of emergency clinic visits. consent to participate. Patients seeking ED frequently can experience Later estimations revealed that about 4000 persons per month visit integrity problems if subjected to questions about their care in a way the ED at the hospital where this study was performed and about 3000 that goes beyond the ‘normal’ procedure as their total life situation persons meet a physician and about 1000 came into contact with the would be examined in the study and not just simply their reason for newly implemented function of a triage nurse [23]. This estimation coming to the ED. The team dealt with this by offering the degree of resembles other Swedish studies showing that about 5% of patients help that met the patients’ needs in a longitudinal aspect rather than account for 20% of the visits [1,24]. just here and now. The study was approved by the Ethical Committee of Lund University D.nr 2012/733. To describe the development of the model, a researcher, the first author (LP), participated in the steer group and the working group. Findings Specific questions were put to the collected data such as; how did the process of change began, how were the groups formed and what The development of a new model for dealing with patients who mandate did they have, and which individuals were included in the frequently arrive spontaneously at hospital emergency department groups. requiring health care. Sample and measures The development of the model began as a top-down process with Patients participating in the study were from the Kristianstad initiatives from the hospital manager and in which managers, from Municipality, age over18 years old, who had sought care at the ED, different organizations and with different professions, were invited where this study took place, four or more times during 2012 and who to participate. This approach created the necessary legitimacy for had met a physician. Excluded were patients who had only met the developing the new model. The inter-professional team, who should

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work with the new model, was appointed later and was not involved in 34-89 years old (mean 64) some of them had developmental the actual development. Which led to that the inter-professional team disabilities. None of the patients were gainfully employed, seven were then established their own working processes and routines and also old age pensioners, two were retired on the grounds of disability and formed routines for cooperation with other caregivers. In this phase four had income support. All had taken their own initiative to visit of the project the developmental process became bottom-up. the ED, and 10 arrived by ambulance. Six patients had home health care and eight had home help service. Six patients had previously The hospital manager gave a directive to design a model for the participated in care planning at the hospital and also at home. management of frequent visitors to ED. The focus was to be on improving patients’ health and to improve cooperation between Team members background characteristic's hospital, primary- and community- health care and to reduce the burden on the ED. This first part of the project was presented in 2011. The Executive inter-professional team consisted of one Emergency The hospital manager then formed a steer group of eleven people. nurse, one Occupational therapist, two Social workers and two The group included the Chief medical officers from the medicine- Pharmacists. The physicians did not partake in the team but were surgical- psychiatric- and emergency- clinic, the Head pharmacist, a consulted. Healthcare strategist (Chairman) a Care developer (project manager) Changes in costs and patient health care utilization related to the and the Primary health care director. The group also included the Head implementation of the team model nurse (MAS, in Swedish) from the municipality and one researcher (LP). The group’s assignment was to develop the new model and to Compared to the six months prior to the study, all 12 patients take decisions in order to create engagement and influence in the reduced their visits to the ED during the six month study period process of planning and implementation. following their inclusion into the new model compared to the six months before (Figure 1). In total, the number of visits to ED was A working group was formed, to further design and test the model. reduced by 55% (73 visits), from 131 visits to 58, by the end of the The group consisted of eight persons including the Project manager study period (Figure 2). and three other members from the Steer group, one Emergency nurse, an operation manager from the primary care, one Health care planner and one Care manager from the municipality.

The new model was formed and presented to the Steer group who took the decision to test it by making a pilot study during the spring of 2012. The model aimed to identify and monitor patients who had sought and received care at the ED four times or more during the past 12 months. The concept of the model was to form an Executive inter-professional team, attached to the ED, working together to gain thorough knowledge of any patient's current symptoms and past medical history. The Executive inter-professional team consisted of one Emergency nurse, one Occupational therapist, two Social workers and two Pharmacists. A number of physicians from different clinics were consulted depending on a patient’s specific problems but were not included in the Executive inter-professional team. Figure 1: Visits 6 months before intervention resp. 6 months after The Emergency nurse identified the patients who met the inclusion intervention. criteria, contacted the patient, informed them and obtained their written consent to participate in the pilot project. Patients who agreed to participate were coded consecutively and asked to complete a self-assessment questionnaire to provide an expanded base of the patient's self-perceived problems. The overall documentation was discussed within the Executive inter-professional team and a common assessment was made. The Emergency nurse then discussed the assessment with the patient's physician at the hospital. After the individual care plan was set up and discussed with the patient it was sent to the relevant health care providers in the municipality, the primary health care and/or the hospital clinic. Current caregivers were asked to provide written feedback on the proposals within two weeks. The pilot study sample, patients and staff

Patient's background characteristics

The patients (n=12) lived in their own homes, had a poor social Figure 2: Study group ED visiting frequency 6 months before and 6 months situation with few social contacts and experienced much loneliness after intervention (n=12). which made them vulnerable. The patients’ ages were between

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The Executive inter-professional team’s working experience of the Another problem was the shortage of funding. The team members model needed more time to meet and talk about the complex needs of patients. It took time to get to know each other; however, by the Results from the interviews with team members are presented end of the study common proposals were being reached faster. below. Interpreted categories are presented in accordance with Hseih Furthermore, it was found that the model was not rooted among the and Shannon’ guidelines [28] and, subcategories are supported with physicians working at the ED since they did not participate in the citations. team discussions. A way to develop together Ambiguity in the patient group Examples of subcategories: interact with each other, secure environment, Examples of subcategories: patients own perspective, not feeling develop continuously and learn from each other. comfortable, give responsibility to the patient.

The composition of the team members was fairly stable throughout The new model involved the Emergency nurse assessing patients the study period. This stability gave the team members opportunities suggested to benefit from the model. The self-assessment questionnaire to learn how to cooperate with each other in order to meet the study’s used was considered to be helpful since it included the patient's own objectives. The team developed together by sharing their professional perspective. skills which contributed to expanding their knowledge concerning patient’s needs. • Self-assessment has been helpful. We (the team) may think that they (the patient) are alone but the patient may not think • It is important to be an intact team, getting to know each other it is a problem but might experience other things as problems. and to confer regarding a specific patient...when listening to each other you can change your image of a situation. The team members experienced that some of the patients were not comfortable with the questionnaire since they did not want to Initially, there were no clear guidelines related to how to work be considered as frequent visitors. However, the majority of the together, however, the team members developed their own practices. patients were positive to being asked to participate and saw it as an Important for developing together was fixed schedules for meetings advantage since they could call the nurse whenever they wished. The and that the nurse worked both as a team leader and as a pilot in team members also reported that these patients frequently phoned the relation to the patients. This split role functioned as a link between the emergency nurse. team and the Steer group as well as between the team and the external care providers and the patient. Discussion Lack of firm support The pilot study contributed to an increased understanding of the process of developing and testing a new model for taking care Examples of subcategories: Shortage of funding, continuous information, lack of time and need of communication. of frequent visitors to a somatic hospital based ED. The pilot study showed a decreasing number of visits after participating in the The team experienced various challenges during the period of new model resulting in a reduction in care costs and, showed the coming together. The team felt that there were weaknesses in their experience from the Executive inter professional team members. cooperation with the Steer group. The first weakness was felt to be It took about 2 years of planning and set up of the frames for the new a lack of continuity among the participants in the steer group and model. During this time all involved had the opportunity to follow the further that it was the Emergency nurse who was the link between the process, intervene if wanting to and to form the final limitations of the groups. Other team members felt they lacked contact with the Steer project. The time that elapsed gave a sound base to the project. group. Even if the urge of creating a new model for handling frequent • It’s only the nurse who has contact with the Steer group. We visitors came from the Hospital Manager the executive team (the team) have never been in contact with them (the Steer members experienced freedom to structure the project in detail by group). They tell us what to do and we just implement it. themselves. They said to have lacked firm directives in the beginning The team members experienced that external health care providers of the project but this led to that they conducted a way of working were not fully supportive of the principles of the new multidisciplinary and working together in their own way. At after sight this had led to model. Initially, the team members received positive feedback from that they had felt responsibility for the project. The inferred quality the external care providers after informing them about the new model. assumption is that a management induced project (top-down) may All of the external health care providers they had been in contact with be accepted and fostered (bottom-up) under freedom. In this case confirmed the need for a new way of working together. Collaboration the freedom led to further steps being taken way beyond the original with some parts of the municipal social care had already begun, project limitations, offering an integration of professional knowledge meaning that the team had contact persons in the external health care between team members. Interprofessional communication has been services who were well versed in the model. However, the external shown to increase the quality of care for frail older people [29]. This health care providers, particularly those professionals, who encounter result is underpinned by Schaik et al [30] who, from a study with inter patients on a daily basis, were not informed. professional teams, draw the conclusion that organizational change often is chosen from the top but ideally should be chosen by the team • As a director for primary care, she finds it difficult to reach out to be respected and empowered. to the operation care. We know she has informed all the other managers...then it has been difficult to reach further to those The number of visits decreased considerably and generated a who meet the patients. 55% reduction in the number of spontaneous re-visits. Before the

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implementation the number of frequent visitors’ spontaneous visits to that qualitative and quantitative data collection was carried out the ED simply clogged up the system due to the overload of patients’ parallel and, later kept separate during the data analysis and then problems to be dealt with by the Emergency duty nurse. Particularly integrated in an overall interpretation [22]. This was carried out given the fact that spontaneous visitors often had complex problems since the researches performed different parts of the data gathering including psychosocial ones [3,7]. All patients in our study had a and analysis separately; LP participated in the Steer group, made complex social situation not suitable for ED practices. Erdem et al. interviews and took part in data analysis, IF analyzed interviews and [31] suggests, in a study on readmission rates in medical care at a took part in data analysis and LJ conducted interviews and took part large hospital in the US, that a large hospital may serve sicker or more in data analysis. All authors contributed to study design and report complex cases which makes care coordination more difficult. Since writing. A weakness in a pilot study is, on one hand the low number the hospital where the study was performed is the largest hospital in of participants, on the other hand, it is meant to give directions for the area that might also be true for this hospital. Erdem further argued managing further investigation, as it did. The pilot study gave a first that broad based interventions are needed to prevent readmission in picture of the model and further investigation is planned. frail patients with multi morbidity and complex medical condition. Conclusion Not least is that necessary in view of frequent visitors’ repeated use of also other care facilities. In a Swedish investigation the authors found This study has provided important information for further a high risk of 5 or more (OR 3.43, CI 3.10-3.78) primary care visits in development of the model in order to increase the knowledge of frequent visitors [32]. The authors also found an increased mortality what is best practice for how to take care of frequent visitors to ED. rate (OR 1.55 CI 1.26-1.90). The new model for dealing with frequent The Executive inter-professional team acted as a support for the visitors had considered the issue of care coordination and managed assessment of patients' underlying needs. Making assessments in an to identify frail patients and thereby made it possible to alert the inter-professional team requires extended time availability for the Emergency nurse and the Executive inter-professional team assigned. staff, however, it can help patients to find the right level of care which According to interviews with the team members the most in turn offers cost reduction for the healthcare system. Increased important part of the new model was the encounters and discussions communication between different professionals within the hospital between the different professions. During the inter-professional and between different caregivers such as ED, primary health care and discussions, a wide understanding of patients' problems and patients community social- and health-care, increases the possibility for the overall situation emerged. A short coming in the study design was patients to be cared for in a sustainable and non-fragmented way. The that no physician participated in the team. Instead the emergency results of this study will be followed by documented descriptions of nurse consulted the physician after the team had met and formed patients’ experiences of the model together with a longitudinal follow their proposals into a care plan. However, we can conclude that the up of staff experiences and cost development. results show that the team worked well without the participation of a physician. Declaration of interest Expanded communication was experienced and described as a The authors confirm that they have no interests to declare. key result of the new model in a way of increased communication Author Contributions with primary- and community care staff which hindered the care being fragmented. Previous studies have shown the importance of Lena Persson is responsible for the content and for all data collection. better continuity of care and of collaboration between health care Ingela Furenback is responsible for the qualitative analysis of the providers to avoid gaps in the quality of taking care of the patients interviews. Liselotte Jakobsson is responsible for statistical analysis. [1,3,4,29]. These results supports our results in that the new approach All of the authors shared the responsibility for the preparation of the in the Executive inter-professional teamwork could change patients’ manuscript. everyday living situation in a positive direction. According to the Acknowledgement team the major difference for the patients was that someone took the time to listen and ask about other matters besides the direct reason or Thanks go to the management of Kristianstad Central hospital cause for their visit. who contributed financially and enabled this study. We would also like to thank the professionals who participated in the interviews and Accumulating information in the Executive inter-professional team the coordination group at the Research Platform for Collaboration was a process of continuous updating. There is still much to be done Health at Kristianstad University for their support. We gratefully among the entities involved in order to establish effective and long- acknowledge Anita Bengtsson Tops, professor, RN, Kristianstad lasting cooperation. Differences exist among different regulations, University, Sweden for providing valuable advice and assistance with disciplines, explanatory models and forms of organization. Extended the content of the manuscript. interaction requires respect for each model in order to deal with and take advantage of these differences [1, 29]. By having a composite References inter-professional team in the emergency department with time to 1. 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Int J Nurs Clin Pract IJNCP, an open access journal ISSN: 2394-4978 Volume 1. 2014. 103